PD - upper limb Flashcards
Shoulder complex: 3 joints and 1 articulation
glenohumeral joint
acromioclavicular joint
sternoclavicular joint
scapulothoracic articulation
Muscles and tendons surrounding the shoulder joint
rotator cuff (SItS: supraspinatus, infraspinatus, teres minor, subscapularis)
Causes of referred shoulder pain
coronary artery disease
pulmonary tumors
gallbladder disease
Shoulder ROM 3 main components
GH motion
scapulothoracic motion
combined GH/scapulothoracic motion
Shoulder ROM (motions and angle)
aBduction: 0-180 (2:1, GH and scapulothoracic) aDduction: 0-45 flexion: 90 extension: 45 internal rotation: 55 external rotation: 40-45
2 general screening maneuvers to evaluate AROM of shoulder
- Apley scratch test
2. “Shoulder Arc”
Apley scratch test
tests AROM of shoulder
pt…
reaches up behind head and touches superior medial angle of opp scapula w/ fingertips (external rotation, abduction)
reaches in front of the chest to touch opposite acromion (internal rotation, adduction)
reaches down behind back to touch inferior aspect of opp scapula (internal rotation, adduction)
shoulder arc
tests AROM of shoulder
pt aBducts arms to 90 degrees w/ elbows straight, turns palms up, then continues to aBduct until hands are over head
pain –> “painful arc”
- pain btwn 60-120 –> subacromial (tendonitis or impingement)
- pain after 120 –> acromioclavicular
Grading of muscle strength
5 – Normal: Complete range of motion against gravity with full resistance
4 – Good: Complete range of motion against gravity with some resistance
3 – Fair: Complete range of motion against gravity
2 – Poor: Complete range of motion with gravity eliminated
1 – Trace: Evidence of muscle contraction, but no joint motion
0 – Zero: No evidence of muscle contractility
Shoulder abduction muscles
middle deltoid (C5, 6) supraspinatous (C5, 6) - 1st 15
secondary: serratus anterior, remainder of deltoid
Shoulder adduction muscles
pectoralis major (C5-T1) latissimus dorsi (C6-C8))
secondary: teres major, anterior deltoid
shoulder flexion muscles
Anterior deltoid (C5) corocobrachialis
Secondary: teres major, anterior deltoid
Shoulder extension muscles
Latissimus dorsi (C6-8) Teres major and minor (C5-6) Posterior deltoid (C5-6)
Secondary: triceps, teres minor
Shoulder internal rotation muscles
Subscapularis (C5-6) pectoralis major (C5-T1) latissimus dorsi (C6-8) teres major (C5-6)
Secondary: deltoid
Shoulder External rotation muscles
Infraspinatous (C5-6) Teres minor (C5)
Secondary: deltoid
Shoulder Scapular elevation muscles
Trapezius (CN XI) Levotor scapulae (C3, 4)
Secondary: rhomboids
dermatome vs. peripheral nerve distribution
dermatome: specific area of skin sensation supplied by a particular spinal nerve root
Peripheral nerve distribution: specific area of skin sensation supplied by a particular peripheral nerve (* peripheral n. may receive input from multiple spinal nerve roots)
How to test C5 dermatome
touch a round patch of skin on lateral aspect of deltoid muscle
How to test T1 dermatome
touch medial aspect of arm
T4
nipple line
Which nerve is frequently damaged in shoulder dislocation?
Axillary nerve
If injured —> patch of decreased sensation on lateral aspect of deltoid & deltoid muscle itself will be weak
Special tests for shoulder
Impingement test Apprehension test Drop arm test Inferior sulcus sign Empty can test Subscapularis lift-off test
Impingement test
tests for impingement of rotator cuff m. and tendons
- Hawkin’s test: pt internally rotates arm w/ thumb facing downward, flex pt’s arm (if impingement —> pain as arm is flexed)
- Neer’s test (modified Hawkin’s test)
Apprehension test
tests for anterior shoulder instability
- Pt supine, shoulder abducted to 90 and ext. rotated.
- Attempt to further ext. rotate shoulder while simult. apply ant. force on post. side of humeral head
- If shoulder ready to dislocate —> will be a look of apprehension on pt’s face and/or pt will resist addl forced ext. rotation
- Relocation test: if post. directed force on ant. shoulder alleviates sx —> evidence of compromised ant. capsule.
Drop arm test
Detects tears in rotator cuff
- Fully abduct pt’s arm, ask pt to slowly lower arm to their side
- Tear in rotator cuff (supraspinatus) will cause arm to drop to side from 90 and pt will be unable to lower arm smoothly
- (aBduction > 90 —> mainly deltoid)
Inferior sulcus sign
- tests for inferior glenohumeral instability
- Distract arm inferiorly (pull downward)
- Simult. palpate AC joint on same side (should be little/no movement)
- Laxity —> indicates inferior GH instability
Empty can test
- Tests supraspinatus (rotator cuff)
- Pt aBducts arm to 90, flex shoulder to 30, and internally rotate as if pouring liquid
Subscapularis lift-off test
- tests subscapularis function
- Pt int. rotates arm behind the back w/ dorsum of hand in contact w/ small of back against resistance
- Inability to lift hand off back —> subscapularis dysfunction
Referred elbow pain
Can be related to pathology of wrist, shoulder and cervical spine
Elbow ROM and angles
Flexion: 180
Extension: 0
Supination: 90
Protonation: 90
Elbow flexion muscles
Brachialis (C4, 6)
Biceps (C5,6)
Secondary: brachioradialis, supinator)
Elbow extension muscles
Triceps (C7)
Secondary: anocneus
Elbow supination muscles
Biceps (C5, 6)
Supinator (C6)
Secondary: brachioradialis
Elbow protonation muscles
Protonator teres (C6) Pronator quadratus (C8-T1) Secondary: flexor capri radialis
Biceps reflex
C5
- Pt’s flexed and relaxed arm is rested on their thigh or abd, your hand supporting arm under medial elbow, your thumb placed on biceps tendon in antecubital fossa
- Tap your thumbnail w/ narrow end of reflex hammer
brachioradialis reflex
C6
- Pt’s flexed and relaxed arm is rested on their thigh or abd, your hand supporting arm under medial elbow, your thumb placed on biceps tendon in antecubital fossa
- tap brachioradialis tendon at distal end of radius w/ flat edge of reflex hammer
triceps reflex
C7
- Pt’s flexed and relaxed arm is rested on their thigh or abd, your hand supporting arm under medial elbow, your thumb placed on biceps tendon in antecubital fossa
- w/ pt relaxed, tap triceps tendon where it crosses olecranon fossa w/ narrow end of hammer
C5 sensation
lateral arm
sensory branches from axillary n.
C6 sensation
lateral forearm to thumb and index
sensory branches from musculocutaneous n.
C8 sensation
medial forearm; antebrachial cutaneous n.
T1 sensation
medial arm; brachial cutaneous n.
Tinel sign (elbow)
designed to elicit tenderness over a neuroma/area of compression within a n.
tap on area of ulnar n. in groove between olecranon and medial epicondyle
If neuroma or narrowing of passageway –> tingling sensation sent down forearm to ulnar side of hand
lateral epicondylitis (tennis elbow) test
stabilize pt’s forearm w/ their elbow extended, forearm protonated, wrist flexed
ask pt to extend wrist against resistance while palpating lateral epicondyle
(like tennis back hand)
pain in lateral epicondyle (site of origin for wrist extensors) –> + sign
medial epicondylitis (golfer’s elbow) test
pt holds arm w/ elbow flexed to 90 degrees, forearm supinated
pt flexes wrist and protonates forearm against resistance while you palpate medial epicondyle
pain in medial epicondyle (site of origin for wrist flexors) –> medial epicondylitis
Additional ROM tests for fingers
Test FDP (ask pt to flex at DIP)
Test FDS (ask pt to flex at PIP)
Extensor testing
Abduction/adduction
Tinel sign (hand)
tap median n. at volar wrist to test for damage/compression of median n.
tingling felt in distribution of median n.
Allen test
evaluates blood supply to hand, demonstrates an intact palmar arch and collateral circulation in hand
(apply pressure to radial and ulnar a. at same time to occlude them, open/close hand several times, pt relaxes hand, first release pressure from radial a., then repeat releasing pressure from ulnar a. Hand should flush pink w/ release of either a.)
Phalen’s test
carpal tunnel syndrome
compression of median n. in carpal tunnel
+ if pt experiences pins/needles when dorsal aspect of hands are placed together, fingers pointing downward w/ wrists flexed to about 90 degrees, held for 60 sec
Finkelstein test
tenosynovitis in wrist
pt makes a fist w/ fingers wrapped around thumb, then deviates hand in ulnar direction
pain over aBductor pollicis longus and extensor pollicis brevis –> tenosynovitis
There are no intrinsic muscle in the hand that are innervated by the __________, and so to test the muscle strength component of this nerve, examine ___________ against resistance.
There are no intrinsic muscle in the hand that are innervated by the RADIAL N., and so to test the muscle strength component of this nerve, examine WRIST EXTENSION against resistance
Wrist extension m.
C6
extensor carpi radialis (radial n.)
sec: extensor carpi ulnaris
Wrist flexion m.
C7
flexor carpi radialis (median n.)
sec: flexor carpi ulnaris
Finger extension
C7
extensor digitorum
Finger flexion
C8
PIP: FDS
DIP: FDP
MCP: lumbricals
Thumb extension
C7
MCP flexion: flexor pollicis brevis
IP flexion: flexor pollicis longus
Thumb flexion
C7,8
MCP flexion: flexor pollicis brevis
IP flexion: flexor pollicis longus
Thumb aBduction
abductor pollicis longus and brevis (C7)
Thumb aDduction
adductor pollicis (C8)
hand sensation dermatomes/nerve roots
C6 –> thumb, index finger
C7 –> middle finger
C8 –> ring finger and small finger
radial n. sensory innervation to hand
web space between the thumb and index finger and the dorsum of the hand to about the level of the PIP joints
median n. sensory innervation to hand
portions of the thumb, index, long and radial side of the ring finger
ulnar n. sensory innervation to hand
lateral surface of the tip of the little finger, ulnar side of ring finger
Allen test
evaluates blood supply to hand and demonstrates intact palmar arch/collateral circulation in the hand
(occlude radial and ulnar a. at wrist, pt open and closes hand, release pressure from one a., hand should flush immediately)
Tinel’s sign
assessing median n. damage or compression, usu at carpal tunnel
tap on median n., tingling will be felt in distribution of median n. sometimes will travel prox toward elbow
Phalen’s test
tests for carpal tunnel syndrome…
compression of median n. in carpal tunnel
pt will feel pins/needles when dorsal aspect of hands are placed together, fingers pointing downwards with wrists flexed to ~90 degrees. Hold position for 60 sec. If no numbness/tingling after this, - result
Finkelstein tests
for tenosynovitis in wrist
pt makes a fist with the fingers wrapped around the thumb, then deviates the hand in an ulnar direction.
pain over the abductor pollicis longus and the extensor pollicis brevis –> tenosynovitisn
